SINGLE POINT OF ACCESS (SPOA)

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1 What Is Single Point Of Access (SPOA)? Onondaga County Department of Mental Health SINGLE POINT OF ACCESS (SPOA) CHILDREN & YOUTH SERVICES In Onondaga County, SPOA was created for the purpose of assisting in identifying high-need, at-risk children and youth, while developing strategies for services in order to maintain them in our community and to develop a system responsive to the needs of families. SPOA assesses the strengths and needs of referred children, provides parental assistance, and addresses the child s past and present services and supports. The completed SPOA process subsequently leads to linking children and youth to the most appropriate services. SPOA is available to families and service providers who are seeking help for a child with an emotional disability. Services Available Through SPOA: The following provides a brief description of services available to *eligible children and youth, ages 5 through 18 (With the exception of the Homeless Prevention Program) referred to SPOA. Services are voluntary and each of the following services is provided at no cost to the families. *Eligibility criteria includes having a DSM IV, Axis I Diagnosis and Serious Emotional Disturbance. Exceptions for some services exist. Community Based Services! Customized Community Services The Youth and Family Development Specialist (YFDS) supports parents or guardians who are raising children with serious emotional challenges. The YFDS, in conjunction with the family and the primary care planner, develops time-limited individualized and specific goals, focusing on skill building. Youth skill building and Parent skill building may include topics such as: impulse control, anger management skills, social skills and interactions, balancing limit setting, increasing skills in active listening, and using positive reinforcement.! Family Support Services Family Support provides case management services that are targeted to the family as a whole, rather than to a specific child. Services include: educational and community advocacy, parent support and skill building, community linkage, and working towards maintaining disturbed children in the least restrictive environment.! Case Management Services Case Managers serve youth that are identified as needing additional support due to a severe emotional disturbance. These mental health professionals team with families to create individualized plans for children, focusing on maintaining children in the least restrictive environment possible. Intensive Case Management Services (ICM) and Supportive Case Management Services (SCM) are determined upon the need of the child. The emphasis is on utilizing the strengths of the child and family to develop the family s natural supports.! Home & Community Based Waiver This is an all inclusive program which provides wrap around services including: respite, care coordination, skill building, family support, crisis intervention, intensive in-home support, as well as linking families to other community supports. This service is directed toward the child who is at imminent risk of placement in a Residential Treatment Facility (RTF) due to severe emotional disturbance. Out of Home Placement Services! The Salvation Army Homeless Prevention Program Serves young adults ages years who have a serious mental illness (Axis I). Provides outreach services targeted to connect and engage young adults who need assistance in the transition from the children s system to the adult system and are at risk of homelessness. Intensive case management is provided from 6 months to 2 years. Clients are provided assistance in completing housing, education, employment, health (mental and physical), and independent living skills goals.! Family to Family Family to Family is a family-based treatment program, which provides an effective alternative to residential care. Surrogate families are trained to maintain and treat seriously emotionally disturbed youth in their homes. There is a strong supportive backup for the surrogate families, as well as extensive treatment and contact with the biological family/guardian. The goal is to return the child to their own family environment.! Toomey Residential, Mather Street (Ages 6 to 13) - Mather Street Children s Community Residence serves children who are severely emotionally disturbed and cannot be maintained in their homes with community supports. The therapeutic milieu focuses on behavior management, self-esteem and skill development. Children must demonstrate a willingness to participate in an individual service plan and adhere to the basic rules of the residence. Family involvement is encouraged.! Residential Treatment Facility (RTF) An RTF meets the needs of severely emotionally disturbed children and adolescents. Services provided include: assessment, psychiatric and psychological services, medical treatment, individual and group psychotherapy, recreation therapy, and special educational services. Families receive support, education, training, and case management. 1 of 20 Revised 12/12/06

2 The SPOA Referral Process: If it is the intention of the referral that the child be considered for: Mather Street Family to Family Home & Community Based Services / Waiver Residential Treatment Facility (RTF) The Following Documents Must Also Be Included:! Psychiatric Evaluation (current to within the last 6 months) - Please include mental status, history of psychiatric care and treatment, DSM IV, emotional strengths and weaknesses, including frustration tolerance, prognosis, and a brief medication history.! Psychological Evaluation (current to within the last 12 months) - Please include intellectual functioning, prognosis, social-affective functioning, any sensory, behavioral, and language skills and deficits, prior history of psychological problems, gross and fine motor coordination and self-help skills.! Psychosocial History (current to within the last 12 months) - Please include family and community relationships, strengths and weaknesses in the familial constellation, emotional and health factors of the family, religious and ethnic affiliation.! Physical/Medical Evaluation (current to within the last 12 months) - Please include a developmental history which contains an assessment of pre and post natal periods, developmental milestones, problems and experiences which have interfered or may interfere with future development, and peer relationships and/or activities.! IEP (current to within the last 12 months) - Please include an assessment of current school status and vocational assets and liabilities; which include where available and appropriate, intellectual and achievement tests. Describe what has been helpful in the classroom to handle disruptive behaviors, if any. Describe what has been helpful in the areas of use of free time, motivation, and affective incentives and reinforcers. The completed referral form and all documentation are sent to: Geri Lynne Jackson, LMFT SPOA Coordinator, Children and Youth Services ONONDAGA CASE MANAGEMENT SERVICES, INC. 220 Herald Place, 4 th Floor Syracuse, New York IMPORTANT NOTE It is essential that the original referral be sent back for processing since it is also a release of information authorizing the SPOA review process. Photocopies and / or faxes of the sections requiring signature are not acceptable and will result in a delay in processing. 2 of 20 Revised 12/12/06

3 ONONDAGA COUNTY SINGLE PORTAL OF ACCESS SINGLE POINT OF ACCESS (SPOA) CHILDREN & YOUTH SERVICES CONSENT FOR RELEASE OF INFORMATION I consent to use and allow the disclosure of protected health information about me for the purpose of arranging services, treatment, payment, and health care operations as described below. I understand that information regarding my health will be used by the appropriate staff of Onondaga Case Management Services, Inc. and/or disclosed to other persons or organizations whenever deemed necessary. I understand that Onondaga Case Management Services, Inc. staff will Provide services to me and/or arrange for services by another health care provider, and/or Arrange for payment for services for me, and/or Operate the business of Onondaga Case Management Services, Inc., and/or Enable other health care organizations to provide services to me, and/or pay for services for me, review the quality and appropriateness of care I will receive, and/or conduct other health care operations as needed. I understand that the information disclosed pursuant to this consent may / may not be re-disclosed by the recipient of the information. (Note: Most health care providers and all health benefit plans are obligated to follow federal rules and state laws for protection of the privacy of your health information. However, those rules and laws do not apply to all organizations.) I understand that there is no time limit on this consent. I also understand that I may revoke this consent at any time. (initial here) (initial here) I confer I am the person who is the subject of the health records that will be used or disclosed and I agree to use and allow disclosure of my health information as described in this consent. Print Name: Signature Date I am the personal representative of the person whose records will be used or disclosed. My relationship to that person is. I agree to the use and disclosure of the health information of Print Name: (child / youth s name) as described in this consent. Signature Date If The Intention Of The Referral Is For the Following Community Based Services: Customized Community Services Family Support Supportive Case Management Intensive Case Management Please Complete Only Pages of 20 Revised 12/12/06

4 Name (Last) (First) Address Date of Birth Age Sex Male Female (Street) I.Q. Date of Test Axis I Diagnosis (City) (Zip Code) (County) Please Note Any Specific Disabilities Social Security Number Medicaid Number Is This Child an SSI Recipient? Ethnicity Yes No Black White Eurasian Hispanic Native American Other Unknown Child / Youth s School District of Origin Parents Mother (Name) Phone Numbers: Home Work Cell (Street) (City) (Zip Code) (County) Father (Name) Phone Numbers: Home Work Cell (Street) (City) (Zip Code) (County) CUSTODIAN Parent DSS DFY Family Court Other If Other, Please Explain: If You Checked DFY or Family Court, What is the Legal Status of the Child? Restrictive Placement Juvenile Offender Youthful Offender Juvenile Delinquent Case Pending Person In Need of Supervision Other If Other, Please Explain: Contact Person Referring Source (Name) (Agency Name) (Phone Number) (Mailing Address) (Relationship to the Child) (City) (Zip Code) (County) 4 of 20 Revised 12/12/06

5 REFERRAL SOURCE IDENTIFICATION! Family / Legal Guardian! Juvenile Justice System! Private Psychiatric Inpatient Hospital! Self! Social Services! Residential Treatment Facility! School/Education System! Other Mental Health Program! Community Residence! State Operated Inpatient Program! Physician! Intensive Case Management! Local Hospital Acute Inpatient Program! Emergency Room! OMRDD! Other: Name of Person Making Referral: Phone #: Address: City: State: Zip: Fax #: Reason for Referral: CHILD & FAMILY HOUSEHOLD INFORMATION Name (First & Last) Age Relationship to Child Is Child Living at Home? 5 of 20 Revised 12/12/06

6 Child s Primary Language:! American Sign Language! English! Spanish! Other (Specify) Child s Living Situation:! Independent Living! 2 Parent Family! 1 Parent Family! 2 Parent Adoptive Family! 1 Parent Adoptive Family! Other Relative s Home! OCFS Family Foster Care! OMH CY Community Residence! Teaching Family Home! OCFS Group Home! DFY Community Group Home! Family Based Treatment! Residential School (SED)! Residential Treatment Center (OCFS)! Residential Treatment Facility (OMH)! Psychiatric Inpatient Care Unspecified! OCFS/DRS Facility! Jail! Homeless/Streets! Grandparents! Private Psychiatric Inpatient Article 31! General Hospital Psychiatric Inpatient Article 28! State Psychiatric Inpatient! Other (Specify)! OCFS Therapeutic Foster Care! Crisis Residence! Runaway Shelter 6 of 20 Revised 12/12/06

7 CHILD EDUCATIONAL INFORMATION Educational Placement:! Regular Class in Age Appropriate Grade! Regular Class Above Grade Level! Regular Class, but Behind at Least One Grade! Special Class for Students with Handicapping Conditions! Residential School for the Educationally (Emotionally) Handicapped! Vocational Training Only! Part-Time Vocational/Educational! High School Graduate/GED! Day Treatment! Home Instruction! BOCES! College! Not Enrolled in School! Other (Specify):! Unknown Name of School District: Name of School: Highest Level of Education Completed: Does This Child Have a Condition, Which is Classified by the Committee on Special Education? No Yes! Emotionally Disturbed! Learning Disabled! Sensory Impaired! Physically Disabled! Other Health Impaired! Multiply Handicapped! None! Unknown School Behavior! Does Not Participate! Has Truancy/Attendance Problems/Cuts Classes! Has Failing Grades! Lacks Friends at School! Assaults Teachers! Does Not Respond to Teacher Demands! Fights with Peers! Frequent Suspensions 7 of 20 Revised 12/12/06

8 CHILD S MENTAL HEALTH CRITERIA A. Diagnosis: Date of Diagnostic Evaluation: Performed By: Axis I: Code # Secondary Axis I: Code # Axis II: Code # Axis III: Code # Axis IV: Code # Axis V: GAF =: WISC III: Verbal Performance Full Scale WISC IV: Verbal Comprehension Perceptual Reasoning Working Memory Processing Speed Full Scale C. Medication for Mental Health Issues Yes No Name Dosage Who Prescribed? Date Prescribed Psychiatric Emergency Services History:! Check if unknown e.g. CPEP, Police, ER Visit Date Disposition Psychiatric Hospitalization History:! Check if unknown Name of Hospital Admission Date Discharge Date # of Days Hospitalized Has This Child Been A Victim Of Sexual Or Physical Abuse? Never Not in Past 6 months One or more times in the past 6 months, not in past 3 months One or more times in the past 3 months, not in past month One or more times in the past month, not in past week One or more times in the past week 8 of 20 Revised 12/12/06

9 Please check below the degree to which this child exhibits the following symptoms or behaviors: Description Never Rarely Sometimes Often Always Unknown 1. Suicidal Attempts 2. Destruction of Property 3. Fire Setting 4. Cruelty to Animals Description 1. Danger to Self 2. Danger to Others 4. Incidence of arson 5. Incidence of destruction of property 6. Runaway 7. Depression 8. Drug Abuse 9. Alcohol Abuse 8. Sexually Aggressive 9. Physical Complaints 10. Developmental Delays 11. Self Care 12. Social Relationships/Functioning 13. Cognitive Functioning/Communication 14. Self Direction 15. Motor Functioning Not Evident Mild Moderate Marginally Severe Severe Unknown FAMILY INFORMATION Benefits or Insurance Receives Pending N/A Who Receives Benefits or Insurance Receives Pending N/A Who Receives Social Security Wages/Earned Income SSI Worker s Comp SSD Unemployment Public Assistance Private Insurance Veterans Trust Fund Medicare Medication Grant Medicaid Section 8 Food Stamps Railroad Retirement Pension Other A. Please Indicate The Family s Strengths That May Be Utilized To Assist The Child With Services: B. Child s Strengths / Interests / Hobbies / Activities: C. Family Strengths and Informal Supports (e.g. Relatives, Community Organization, Schools): 9 of 20 Revised 12/12/06

10 SERVICE SUPPORTS INFORMATION Services: HCBS Waiver Intensive Case Management Supportive Case Management Family Support CCSI Customized Services Home Based Crisis Intervention Clinic Treatment Private/Individual Therapy Medication Management Family To Family Day Treatment Respite Vocational Training ADL or Independent Living Skills Alcohol Abuse Treatment Private Psychiatric Facility General Hospital Psychiatric Facility OMRDD Developmental Center Other, Specify: Other, Specify: Other, Specify: Currently Receives Received During Last 12 Months Currently Needs Current Community Contacts (e.g. Mental Health, DSS, Counselor, Probation Officer, School Representative): Agency/Organization Name Address Phone 1. Considering Issues Noted, Describe The Family s Individualized Care Needs. (Please be as Specific as Possible): For Parent/Guardian: Strongly Disagree Disagree Neutral Agree Strongly Agree I feel hopeful that there is help for my child and family (check one). 10 of 20 Revised 12/12/06

11 Not Applicable SED CHECKLIST SED CHECKLIST: To Document Youngster with Serious Emotional Disturbance MINIMUM REQUIREMENTS FOR SED: Criterion A must be met, and both parts of B or C must be met. Check All That Apply: Youngster Meets Age Requirement (under 18 years of age). A. Diagnosis of Designated Emotional Disturbance. Youngster Has DSM IV Psychiatric Diagnosis Other Than: Alcohol Or Drug Disorders (291.X, 292.Xx, 303.Xx, 304.Xx, 305.Xx). Organic Brain Syndromes ( 290.xx, 293.xx, 294. x). Developmental Disabilities (299.xx, 315.xx -319x). Social Conditions (V Codes) ICD-9-CM Diagnoses Not Having a DSM IV Equivalent B. Extended Impairment in Functioning Due to Emotional Disturbance. (Both parts of B must be met.) Over the last 12 months, continuously or intermittently, youngster has experienced functional limitations due to emotional disturbance. Problems must be moderate in at least two areas, or severe in at least one area. 1. Self Care personal hygiene; obtaining and eating food; dressing; avoiding injuries. 2. Family Life capacity to live in a family or family-like environment; relationships with parents. 3. Social Relationships establishing and maintaining friendships; interpersonal interactions with peers, neighbors, and other adults; social skills; compliance with social norms; play and appropriate use of leisure time. 4. Self-Direction/Self-Control ability to sustain focused attention for long periods of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability. 5. Learning Ability school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school. During the last 12 months, continuously or intermittently, youngster has rated 50 or less on the Children s Global Assessment Scale (CGAS) or the Global Assessment of Functioning (GAF) because of emotional disturbance. C. Current Impairment in Functioning with Severe Symptoms. (Both parts of C must be met.) Youngster currently rates 50 or less on the CGAS (or GAF) because of emotional disturbance. Within the past 30 days, youngster has experienced at least one of the following: 1. Serious suicidal symptoms or other life-threatening, self-destructive behaviors. 2. Significant psychotic symptoms (hallucinations, delusions, bizarre behavior). 11 of 20 Revised 12/12/06

12 3. Behavior caused by emotional disturbances that placed the youngster at risk of causing personal injuries or significant property damage. ATTACHMENT II: AT RISK CHECKLIST A. TO DOCUMENT YOUNGSTER AT RISK OF OUT-OF- HOME PLACEMENT Check all that apply: Youngster meets age requirements (under 18 years of age). Failed adoption(s). Parent with serious/persistent mental illness. Parent with history of chronic alcohol and/or drug abuse. Youngster has experienced at least one of the following: Has been a victim of physical, emotional or sexual abuse, or severe neglect. Has been a victim of, or witness to, serious violent crime or domestic violence. Has experienced residential disruption caused by: Out-of-Home placement due to emotional disturbance. Multiple family separations. Extended period of homelessness. B. CHILD IS AT RISK OF RESIDENTIAL PLACEMENT IF ANY ONE OF THESE CONDITIONS IS MET There is a current psychiatric/psychological evaluation recommending placement. CSE has approved/is considering residential placement. There is a pending application for RTF before the PACC. Request for placement has been received by the DSS residential placement unit. Child is awaiting placement through the juvenile justice system. Child has experienced a previous residential placement. 12 of 20 Revised 12/12/06

13 Complete This Page Only When Applying For the Homeless Prevention Program Request For Screening For Homeless Prevention Program Name of Child: Current Address: I am requesting that my child s referral packet be submitted to the ICC Agency for screening of eligibility to apply for the Homeless Prevention Program. I also understand that the request for screening is not an application for enrollment in the HPP. I understand that the referral packet will be checked for completeness. The ICC agency may need to contact me or the referral source for further clarification or to request additional documentation. I believe that my child qualifies for the Homeless Prevention Program because he/she: Is at least 16 years of age. Has been given an Axis I mental health diagnosis by a doctor. Has recently been, or is currently due to be, discharged from a residential treatment facility, state inpatient facility or community residence. Is at risk of becoming homeless. Is in need of intensive case management support services. Is in need of learning independent living skills to successfully live in the community. I understand that this screening is necessary before we make formal application to the Homeless Prevention Program. Parent/Guardian Signature: Parent/Guardian name (print): Child s Signature (if appropriate): Date: 13 of 20 Revised 12/12/06

14 STOP HERE FOR COMMUNITY BASED SERVICES Continue Only For The Following Services: Mather Street Residence Requires Completion of Pages 3-15 Family To Family Requires Completion of Pages 3-15 Home and Community Based Service / Waiver Requires Completion of Pages 3-16 Residential Treatment Facility Requires Completion of Pages 3-20 Please Note That The Following Documents Must Also Be Included:! Psychiatric Evaluation (current to within the last 6 months) - Please include mental status, history of psychiatric care and treatment, DSM IV, emotional strengths and weaknesses, including frustration tolerance, prognosis, and a brief medication history.! Psychological Evaluation (current to within the last 12 months) - Please include intellectual functioning, prognosis, social-affective functioning, any sensory, behavioral, and language skills and deficits, prior history of psychological problems, gross and fine motor coordination and self-help skills.! Psychosocial History (current to within the last 12 months) - Please include family and community relationships, strengths and weaknesses in the familial constellation, emotional and health factors of the family, religious and ethnic affiliation.! Physical/Medical Evaluation (current to within the last 12 months) - Please include a developmental history which contains an assessment of pre and post natal periods, developmental milestones, problems and experiences which have interfered or may interfere with future development, and peer relationships and/or activities.! IEP (current to within the last 12 months) - Please include an assessment of current school status and vocational assets and liabilities; which include where available and appropriate, intellectual and achievement tests. Describe what has been helpful in the classroom to handle disruptive behaviors, if any. Describe what has been helpful in the areas of use of free time, motivation, and affective incentives and reinforcers. 14 of 20 Revised 12/12/06

15 Addendum: In addition to the Universal Referral Form, please complete the following forms for the following services: Mather Street Residence, Family To Family, Home & Community Based / Waiver Services, & RTF Has This Child Been Freed For Adoption? Yes No Child / Families Spiritual / Religious Preference: Out of Home Placement History (Does Not Include Psychiatric Hospitalizations): Date First Placed Out of Home: Current Placement: Placement History: Dates: Significant Developmental Events: Hereditary, Chronic or Debilitating Illnesses Present in Biological Family: Explain Any Pertinent Facts About This Child If Not Already Included In Accompanying Clinical Material: Page 15 of 20 Revised 12/12/06

16 Complete This Page Only When Applying For Waiver Services Request For Screening For Home & Community Based Services / Waiver Name of Child: Current Address: I am requesting that my child s referral packet be submitted to the ICC Agency and the Local Governmental Unit for screening of eligibility to apply for the Home and Community Based Services (HCBS) Waiver. I also understand that the request for screening is not an application for enrollment in the HCBS Waiver. I understand that the referral packet will be checked for completeness. The ICC agency may need to contact me or the referral source for further clarification or to request additional documentation. I believe my child qualifies for the waiver because he/she:! Is between 5 and 18 years of age.! Meets the definition of serious emotional disturbance.! Requires or is at imminent risk of needing psychiatric inpatient services for individuals under 21.! Has complex health or mental health care needs.! Has service and support needs that cannot be met by just one agency.! Is capable of being cared for in the community if provided appropriate access to Waiver services.! Has a viable and consistent living environment and I am willing to participate in the HCBS Waiver and support my child at home and in the community. I understand that if my child is enrolled in the HCBS Waiver he/she may receive Waiver services and any needed services available under the Medicaid State Plan for which he / she is eligible with the exception of Intensive Case Management, Supportive Case Management, Community Residence, Family Based Treatment, other Waiver programs and comparable programs in other service systems (e.g., DSS Therapeutic Foster Care). I understand that this screening is necessary before we make formal application to the HCBS Waiver for children and adolescents with serious emotional disturbance. Parent/Guardian Signature: Parent/Guardian Name (print): Child s Signature (if appropriate): Date: Page 16 of 20 Revised 12/12/06

17 The Following Sections Apply to RTF Applications Only Stop Here For All Referrals Other Than Residential Treatment Facility Applications : All RTF Referrals Must Include the Following Information in Order to be Processed! Referral Summary Please attach a brief summary of the most salient features of the case, including examples and descriptions of behaviors that typify the child or youth s response to current placement, include current information regarding performance of age-appropriate activities, interests, self-care skills, ability to relate to others, and certification by a mental health professional, who is familiar with the case that the materials attached accurately reflect the child or youth s current level of functioning. Please illustrate how all-available lower levels of care have been accessed and utilized.! Psychiatric Evaluation (current to within the last 6 months) - Please include mental status, history of psychiatric care and treatment, DSM IV, emotional strengths and weaknesses, including frustration tolerance, prognosis, and a brief medication history.! Psychological Evaluation (current to within the last 12 months) - Please include intellectual functioning, prognosis, social-affective functioning, any sensory, behavioral, and language skills and deficits, prior history of psychological problems, gross and fine motor coordination and self-help skills.! Psychosocial History (current to within the last 12 months) - Please include family and community relationships, strengths and weaknesses in the familial constellation, emotional and health factors of the family, religious and ethnic affiliation.! Physical/Medical Evaluation (current to within the last 12 months) - Please include a developmental history which contains an assessment of pre and post natal periods, developmental milestones, problems and experiences which have interfered or may interfere with future development, and peer relationships and/or activities.! IEP (current to within the last 12 months) - Please include an assessment of current school status and vocational assets and liabilities; which include where available and appropriate, intellectual and achievement tests. Describe what has been helpful in the classroom to handle disruptive behaviors, if any. Describe what has been helpful in the areas of use of free time, motivation, and affective incentives and reinforcers. Page 17 of 20 Revised 12/12/06

18 CONSENT FOR REVIEW BY A PREADMISSION CERTIFICATION COMMITTEE FOR POSSIBLE PLACEMENT INTO A RESIDENTIAL TREATMENT FACILITY Youth s Name (Last) (First) (M.I.) Youth s Date of Birth Youth s Address Agency Name Agency Address I authorize the Onondaga County SPOA and to release clinical and educational (Source of Referral) Information to the Central New York Regional Preadmission Certification Committee. I understand that the Central New York Regional Preadmission Certification Committee will review and evaluate this information as well as recommendations made by the SPOA to determine my eligibility for services in a Residential Treatment Facility. Furthermore, I authorize the Central New York Regional Preadmission Certification Committee to release clinical/educational information, and to refer me to the appropriate Residential Treatment Facility(s) for possible placement. It is understood that this information will be used to evaluate me for possible placement into a Residential Treatment Facility, and that the Central New York Regional Preadmission Certification Committee and the RTF(s) will maintain the confidentiality of this information. I also understand that I have the right to cancel my permission to release information any time before it is released. This consent to release information will expire 180 days from this date. Signature of Child or Youth (Where Appropriate and Available) Signature of Parent / Guardian Printed Name Signed Signature of Witness Printed Name Signed Signature of Person Completing Form Printed Name Signed Relationship to the Child Date Signed Title Date Signed Title Date Signed Witness & Person Completing Form Cannot be the Same Person Page 18 of 20 Revised 12/12/06

19 Central New York Area Children & Youth Educational Verification Form A youth that will be reviewed for the RTF eligibility by the CNY PACC should also be reviewed by the CSE of the district of residence to determine the presence of an educationally handicapping condition. Please complete the bottom of this form and return it as soon as possible to: Kim Gilmore, MA-PA, LMSW Children and Family Specialist NYS Office of Mental Health 545 Cedar Street Syracuse, NY PLEASE PRINT OR TYPE YOUTH S NAME: D.O.B.: MOST RECENT PUBLIC SCHOOL DISTRICT CERTIFYING HANDICAPPING CONDITION: DATE OF CERTIFICATION: SOURCE OF INFORMATION (NAME / TITLE / AGENCY): PERSON COMPLETING THIS FORM: RELATIONSHIP: DATE: Page 19 of 20 Revised 12/12/06

20 State of New York OFFICE OF MENTAL HEALTH REQUEST FOR DISABILITY DETERMINATION This is to request that a Preadmission Certification Committee designated by the Office of Mental Health and the Department of Social Services determine whether is disabled for the purposes of the Medical Assistance Program. I submitted this request in conjunction with an application for admission of to a residential treatment facility for children and youth (RTF). I authorized the Preadmission Certification Committee (PACC) to review and evaluate any clinical information it has received to assess whether is disabled. I also authorized the PACC to make any investigation necessary to confirm or verify this information or to collect additional information necessary to determine whether he/she is disabled. If is certified by the PACC as eligible for placement and referred to a RTF, I may apply for Medical Assistance Benefits to help pay for the cost of his / her care in the RTF. I understand that this is not an application for Medical Assistance benefits, and that the PACC will be deciding whether is eligible for Medical Assistance. I also understand that the results of this disability determination will not affect any Medical Assistance benefits that he/she may be receiving currently. Signature Relationship to Applicant Date Page 20 of 20 Revised 12/12/06

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